Provider Demographics
NPI:1841533213
Name:DEMATTEO, GINA MARIE (TLLP)
Entity type:Individual
Prefix:MS
First Name:GINA
Middle Name:MARIE
Last Name:DEMATTEO
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:MRS
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:MESSISCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TLLP
Mailing Address - Street 1:1821 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2254
Mailing Address - Country:US
Mailing Address - Phone:313-773-2305
Mailing Address - Fax:
Practice Address - Street 1:1660 FORT ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183
Practice Address - Country:US
Practice Address - Phone:734-304-4159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist